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Figure 3.36 A bulging of the posterosuperior wall of the external auditory canal in a 4-year-old child. A similar picture was also seen in the other ear (see CT scan in Fig. 3.37).

Scan Ear Bleeding

Figure 3.37 CT scan of the same case as in Figure 3.36. The middle ear and mastoid are occupied by an isointense mass, A frozen section obtained during surgery revealed the presence of histiocytosis X. The patient was referred to a specialized center for appropriate staging and therapy with cyto-toxic drugs and corticosteroids.

Figure 3.37 CT scan of the same case as in Figure 3.36. The middle ear and mastoid are occupied by an isointense mass, A frozen section obtained during surgery revealed the presence of histiocytosis X. The patient was referred to a specialized center for appropriate staging and therapy with cyto-toxic drugs and corticosteroids.

Other Pathologies

Polyp Tympanic Membrane

Figure 3.38 Polyp in the external canal in a child presenting with continuous otorrhea and hearing loss. A CT scan (Fig. 3.39) shows the presence of a soft-tissue mass eroding the intercellular septae of the mastoid and the ossicular chain, suggestive of cholesteatoma. This was confirmed during surgery.

Figure 3.38 Polyp in the external canal in a child presenting with continuous otorrhea and hearing loss. A CT scan (Fig. 3.39) shows the presence of a soft-tissue mass eroding the intercellular septae of the mastoid and the ossicular chain, suggestive of cholesteatoma. This was confirmed during surgery.

Scan Hearing Loss

Figure 3.39 CT scan, axial view. The entire mastoid is occupied by a soft-tissue mass. The intercellular septae of the mas-toid and the ossicular chain are absent.

Figure 3.39 CT scan, axial view. The entire mastoid is occupied by a soft-tissue mass. The intercellular septae of the mas-toid and the ossicular chain are absent.

Chronic Suppurative Otitis Media

Figure 3.40 Another example of chronic suppurative otitis media with cholesteatoma that manifests with an aural polyp. Though cholesteatoma presents frequently in this manner, it is absolutely essential to abstain from taking a biopsy of the polyp in the outpatient clinic without performing a CT scan of the temporal bone (see Fig. 3.41).

Temporal Bone Lab Specimens

Figure 3.41 The otoscopic view is very similar to that in Figure 3.40. In this case, however, the diagnosis is that of an en-plaque supratentorial meningioma. An outpatient polypectomy in this case might lead to excessive bleeding (see MRI, Figs. 3.42 and 3.43).

Figure 3.40 Another example of chronic suppurative otitis media with cholesteatoma that manifests with an aural polyp. Though cholesteatoma presents frequently in this manner, it is absolutely essential to abstain from taking a biopsy of the polyp in the outpatient clinic without performing a CT scan of the temporal bone (see Fig. 3.41).

Figure 3.41 The otoscopic view is very similar to that in Figure 3.40. In this case, however, the diagnosis is that of an en-plaque supratentorial meningioma. An outpatient polypectomy in this case might lead to excessive bleeding (see MRI, Figs. 3.42 and 3.43).

Bleeding Mri
Figure 3.42 MRI with gadolinium enhancement, axial view. The tumor (arrows) is located in the temporal fossa and reaches the area of the petrous apex and Meckel's cavity.

Figure 3.43 MRI with gadolinium, coronal view. The meningioma displaces the temporal lobe upwards (arrows); pathognomonic tails of the dura are visible.

Ear Coronal View
Figure 3.44 Left ear. Glomus jugulare tumor with extension into the external auditory canal. A biopsy of this lesion might lead to severe and often difficult-to-control hemorrhage.

Figure 3.45 Left ear. Another example of a glomus tumor.

Growth Tympanic MembraneInvasive Cholesteatoma

Figure 3.46 Pulsating neoplasm in the external auditory canal. MR I (Fig. 3.47) revealed the presence of a glomus jugu-lare tumor involving the vertical internal carotid artery.

Mri Image Internal Auditory Canal

Figure 3.47 MRI of the same case. A glomus jugulare tumor engulfing the vertical portion of the internal carotid artery is clearly visible.

Figure 3.46 Pulsating neoplasm in the external auditory canal. MR I (Fig. 3.47) revealed the presence of a glomus jugu-lare tumor involving the vertical internal carotid artery.

Figure 3.47 MRI of the same case. A glomus jugulare tumor engulfing the vertical portion of the internal carotid artery is clearly visible.

• Carcinoma of the External Auditory Canal

Basal cell carcinoma is more frequent in the auricle, particularly in subjects with long exposure to the sun. On the other hand, squamous cell carcinoma accounts for about three quarters of invasive tumors of the external auditory canal and the middle ear. In about 11% of cases, cervical lymph node metastases are present at the time of diagnosis. The most common symptoms include otorrhea, otalgia, hearing loss, facial nerve paralysis, and vertigo. An accurate microscopic examination is important for proper evaluation of the lesion extension. Frequently, an exfoliative lesion is noted, whereas an ulcer is present in other cases. Carcinoma should be suspected in the case of a persistent otitis externa characterized by pain and otorrhea that does not resolve adequately with medical treatment. A biopsy of the lesion will clear any doubts. It is important to perform an accurate examination of the upper deep cervical, postauricular, and parotid lymph nodes (anterior extension of the tumor). The cranial nerves are also evaluated. The facial nerve is the most frequently involved. Involvement of the mandibular nerve indicates tumor extension towards the glenoid fossa. A high-resolution CT scan (bone window) is the most important radiological investigation as it permits the evaluation of bone erosion at the level of the external auditory canal and middle ear. MRI with gadolinium allows the evaluation of tumor extension into the soft tissues.

The tumor should be considered to be T3 or T4 if there is infiltration of the posterior or middle cranial fossae, or invasion of the jugular foramen or glenoid fossa. In such cases, whatever the modality of treatment, the prognosis is almost always poor.

Surgery consists of en-bloc removal of the tumor and a trial to include a safety margin of the surrounding healthy tissue in the specimen. Postoperative radiotherapy should be subsequently performed.

Healthy Tempanic Membrane

Figure 3.48 An exfoliative neoplasm that occupies the external auditory canal. The patient complained of otalgia and attacks of bloody otorrhea of 1-month duration. A biopsy was taken and pathologic examination revealed the presence of squamous cell carcinoma. A CT scan (Fig. 3.49) demonstrated erosion of the external auditory canal, particularly its anteroinferior wall, without breaking into the glenoid fossa. En-bloc removal of the tumor was performed, together with a superficial parotidectomy. Radiotherapy was performed postoperatively.

Figure 3.48 An exfoliative neoplasm that occupies the external auditory canal. The patient complained of otalgia and attacks of bloody otorrhea of 1-month duration. A biopsy was taken and pathologic examination revealed the presence of squamous cell carcinoma. A CT scan (Fig. 3.49) demonstrated erosion of the external auditory canal, particularly its anteroinferior wall, without breaking into the glenoid fossa. En-bloc removal of the tumor was performed, together with a superficial parotidectomy. Radiotherapy was performed postoperatively.

Figure 3.49 CT scan demonstrates erosion of the antero-inferior wall of the external auditory canal. The glenoid fossa is not invaded.

Tympanic Hemorrhage

Figure 3.50 Squamous cell carcinoma protruding through the external auditory canal with extension into the glenoid fossa and infiltration of the middle fossa dura (see CT scan, Fig. 3.51 and MRI, Fig. 3.52). Palliative surgery was performed followed by radiotherapy.

Mastoid Cancer Mri
Figure 3.51 CT scan. The carcinoma occupies all of the middle ear and the mastoid. The glenoid fossa and the middle fossa plate are eroded.
Middle Ear Bleeding Present Externally

Figure 3.53 Squamous cell carcinoma with posterior extension. The mass ifiltrates the skin of the posterior wall of the external auditory canal (see CT scan, Fig. 3.54) as a result of which en-bloc resection and subsequent radiotherapy were performed.

Tympanic Membrane Mri
Figure 3.52 MRI shows marked anterior extension of the tumor into the infratemporal fossa.

Figure 3.53 Squamous cell carcinoma with posterior extension. The mass ifiltrates the skin of the posterior wall of the external auditory canal (see CT scan, Fig. 3.54) as a result of which en-bloc resection and subsequent radiotherapy were performed.

Tempanic Membrane Rupture
Figure 3.54 CT scan, axial view. The tumor has eroded the most lateral portion of the posterior bony wall.
Tumor Tympanic Membrane

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